THE HISTORY OF CLEFT PALATE SURGERY AT THE DEPARTMENT OF PLASTIC SURGERY IN PRAGUE

The history of cleft palate surgery at the Department of Plastic Surgery in Prague was characterized by the use of a variety of surgical methods and thus documented the intense efforts of Burian in researching into a procedure which would not only promote satisfactory healing but also not interfere with the subsequent growth of the maxilla.

In the twenties, during the first year of his surgical treatment of cleft palate, Burian used the Langenbeck-Diefenbach-Warren method. He believed that the survival of anteriorly based mucoperiosteal flaps depends, during the strain to which they are exposed, on their biologic value, and he attempted to increase this by dividing the procedure into two stages. During the first stage lateral incisions were made and mucoperiosteal flaps were raised from the bone. The operation was terminated after a week.

He was satisfied that the delay rendered the tissue of the flap thicker, increased blood supply and encouraged more favourable healing after the final suture. He also attempted to relieve the tension in the suture by pulling a silver wire through muscles of the soft palate and through the periost of the hard palate, with knots made on each side over small lead plates, according to Brophy.

At this time Burian supplemented the operation of the palate by using a lower based musculomucosal flap raised from the posterior pharyngeal wall as suggested in 1876 by Trendelenburg and newly proposed and realised in 1924 by Rosenthal. Burian was aware of the attempt of Passavant from the end of 19th century to perform a secondary retroposition of the palate as a whole, and when he became acquainted with the papers published by Lvov in 1920 and Halle in 1928 he began to carry out a pushback in two stages: first a suture of the palate, with the pushback during the second stage.

When Burian learnt of Limberg’s procedure from 1933 he performed the operation in one stage, with an extension of incision up to the mandible and fracturing of the hamulus pterygoideus. He was well aware of the drawbacks of these procedures, which consisted in cutting off the nasal layer from the posterior margin of the palatal plates. This resulted in a defect which healed only per secundam, and in marked cicatrisation of the nasal surface of the retropositioned palate. Therefore he started to use a primary velopharyngeoplasty with a lower based pharyngeal flap (Rosenthal), or preferably an upper based flap according to the procedure devised by Sanvenero-Roselli.

However, Burian was still aware that these and numerous other procedures proposed in the twenties paid little attention to the function of the reconstructed palate, and therefore he was looking forward to an operation which, in his words, “would not harm the already abnormally developed organs and which would use local tissues in a way consistent with their normal participation in the development of the pertinent structures”.

This method was devised by Victor Veau and brought a fundamental change in the approach to palate surgery. He showed that it was possible to use the mucoperiost from the nasal sides of the palatal plates for palatoplasty. The bloody surface of palatal oral flaps was completely covered with nasal periost from the nasal side without leaving an open wound which would be exposed to infection, granulation, or shrinking. Veau also recognised the necessity to restore the muscle unit of the soft palate. This can be attained only by carefully suturing together the muscles of both halves of the velum. He did not use relaxation incision on the sides of the velum or mobilisation of muscles.

On the basis of this knowledge and his experience up to the fifties Burian performed palate repair at the age of 5–6 years with the use of 2, 3 or occasionally even 4 oral flaps. The retroposition of the palate was preceded by mobilisation of neurovascular bundles from the foramen palatinum majus, which were carefully protected from any kind of injury or even cutting. At the same time he primarily sutured into the velum an upper based pharyngeal flap.

In 1954 Burian summed up his own experience by publishing the weighty monograph Surgery of Harelip and Cleft Palate.

Burian never neglected the scientific aspects of his surgical activities. He carefully documented his work with his own drawings made into medical reports, and with photos obtained in all phases of treatment, dental casts and X-rays, and he set up a detailed scientific register. This documentation is still kept according to the principles laid down by Burian, and after 70 years today it includes almost 190,000 histories of hospitalised patients with more than 10,000 patients with cleft lip and palate.

In 1957 Burian created a scientific background for clinical practice when he established at his institute an affiliated, well-equipped Laboratory for Congenital Malformations with genetic, teratologic, histologic, electrophysiologic and immunologic units, an orthodontic department and a centre for investigation into the transplantation of tissues. Thus after his death in 1965 Burian bestowed upon us a heritage which allows us to continue our work steadily and adhere to his aim of further improving the treatment and care of patients in general and of individuals affected by facial clefts in particular.

In our opinion the most important heritage which Burian bestowed upon us consists of two items: the first is his philosophy of the approach to the cleft patients. This comprises the need to understand the varying psychological aspects of affected individuals and in the same time to proceed in harmony with the required multidisciplinary and continuous phases of surgical and conservative therapy applied from birth up to adulthood. The second point is based on the need to perform investigations which could provide a deeper insight into the character of individual anatomic and physiologic peculiarities requiring remedy. To carry out surgical repair of pathologic deviations and to provide simultaneously favourable conditions for future growth and development of all involved tissues. If these conditions are present, then it is necessary to make sure that they are not disturbed and that the tissues should be allowed to cope with the situation. In accordance with these premises and in order to achieve harmless reconstruction of the region affected by facial cleft the following conditions should be fulfilled:

1. The time schedule for individual steps of surgical treatment should be determined with regard to the growth pattern of the operated structures, as well as to the fact that any type of surgery results in a short term reduction of growth rate.
2. In each individual case it should be stated which structure will show an adequate growth-rate and will improve its shape after being incorporated into a functional unit (prolabium in bilateral clefts) and which structure is actually deficient and thus requires an addition of bulk.
3. In an insufficiency of tissue bulk should be added either from the immediate vicinity (to a hypoplastic skin of the philtrum a flap from the lateral side), or by a transfer from distant parts of the body (bone grafting in defects of the maxilla), or by transposition (pushback of a short palate).
4. In atypically situated or deformed tissues should be their natural shape should be restored (straightening of nasal septum) or they should be moved in the right direction (the proximal insertions of muscles in cleft lip and palate are detached and folded down into a horizontal position).
5. A more favourable development of individual structures should be stimulated by the restoration of functional units in their vicinity (the effect of the reconstructed labial muscle on the development of the maxilla), by reinforcing their base (the effect of bone implantation under the base of the ala on nasal development), or by adding tissue with an adequate nerve and blood vessels supply (the effect of musculomucosal pharyngeal flap on a rapid rehabilitation of the palate).
6. The operation should be carried out without causing harm; no tissue should be damaged, the periost in the vicinity of dental buds should not be raised, unsutured defects should not be left because of subsequent scarring, and correct degree of mobilisation should avoid tension in the suture.
7. The restoration of function within the reconstructed area should be accelerated by using of all available methods of rehabilitation, chiefly by massage, exercises of labial and palatal motion and by logopedic training. A primary condition of therapeutic success is the complex approach to the therapy of facial cleft. Alongside a well co-ordinated program of surgery, it is essential to establish close co-operation with other specialists participating in the rehabilitation of cleft patients. This refers specially to pediatric and otolaryngologic care, which is important because of the frequent occurrence of respiratory and middle ear infections in these patients, as well as to the continuous dental (and in particular orthodontic) treatment and indispensable phoniatric and logopedic therapy. Assistance provided by a qualified anaesthesiologist, X-ray specialist, psychologist, psychiatrist and neurologist should also be included. Since modern therapy can not proceed without the verification of clinical procedures and experiments by specialist in theoretic branches, it is necessary to co-operate with histologists, anatomists, electrophysiologists, geneticists, teratologists, etc.

It represents a great advantage, both for the patient and for all members of the cleft team, when all specialists who co-operate in the treatment of the clefts have their consulting offices in the building of Plastic Surgery. We managed to attain this goal in Prague in the new building inaugurated 25 years ago.

When Prof. Burian died in 1965 he left as his legacy a well-established institute with efficient organization including a therapeutic and research department. His successors continued to uphold his opinion that a plastic surgeon should never be satisfied with the results obtained and that he must steadily strive to achieve even greater benefits. Above all, efforts should be aimed at the steady improvements of surgical treatment and of postoperative rehabilitation of the patients. The surgeon should not be afraid to go to laboratories and to dissecting rooms in order to gain motivation for his clinical work. He must learn to transmit enthusiasm for co-operation to specialists from other branches of medicine in order to establish the well-functioning multidisciplinary management of cleft lip and palate.

Address for correspondence:

M. Tvrdek, M.D.
Department of Plastic Surgery
3^rd Medical Faculty Charles University, Prague
Šrobárova 50
100 34 Prague 10
Czech Republic
E-mail: tvrdek@fnkv.cz